Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma)

If yes, please detail them here, otherwise please type N/A

Are you currently taking any medications?

If yes, please detail them here, otherwise please type N/A

Have you had any surgeries in the past year?

If yes, please detail them here, otherwise please type N/A

Do you smoke?

Do you consume alcohol?

If yes, how much a day/weekly?

Who diagnosed your quit smoking?

Please provide more detail here

How long have you had symptoms?

How often are your symptoms?

What symptoms do you notice most?

Do any triggers worsen it? (e.g., activity, lying down, certain foods)

Have you tried any treatments or self-care already?

Any red flag symptoms? (e.g., severe pain, difficulty breathing or swallowing, rash with fever)

Have you been prescribed treatment for this before?

Understanding of Risks

I have been informed about the potential side effects and interactions of the prescribed medication for Quit Smoking.

Medical Guidance

I agree to consult with my healthcare provider before starting any new medication.

I understand that the information provided in this assessment will be reviewed by a licensed pharmacist before my order is processed.

Consent to Share Information

I consent to my personal and medical information being used to assess my suitability for the prescribed medication.

I understand that my information will be kept confidential and used solely for the purpose of this assessment.

Confirmation

I confirm that the information provided in this assessment is accurate and complete to the best of my knowledge.

I understand that providing false information may result in my order being cancelled and may have health implications.